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Service experts discuss progress in recognizing, treating PTSD and TBI

By Cheryl Pellerin, DoD News, Defense Media Activity May 2, 2017

WASHINGTON -- Heads of military centers and programs targeting post-traumatic stress disorder and traumatic brain injury in service members and their families reported progress Friday in the timely recognition and treatment of these and related health conditions.

Testifying before the House Armed Services Committee's military personnel subcommittee on Defense Department clinical research and program assessment for PTSD and TBI were Navy Capt. (Dr.) Mike Colston, director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, and Air Force Col. (Dr.) Steven Pflanz, deputy director of psychological health for the Air Force.

Joining them on the panel were Army Lt. Col. (Dr.) Chris Ivany, chief of behavioral health in the Army Office of the Surgeon General, and Navy Capt. (Dr.) Thomas Johnson, site director for the Navy Intrepid Spirit Concussion Recovery Center at Camp Lejeune, North Carolina.

EMPHASIS ON PREVENTION

Colston began the testimony by noting that last year about a quarter of service members were seen for PTSD, TBI or a mental health condition. "We made PTSD and TBI leadership issues with an emphasis on prevention," he said, describing recent progress.

PTSD incidents decreased from 17,000 to 14,000 from 2012 to 2015, and TBI incidents decreased from 31,000 to 23,000 over the period, he said. The center expanded access to care by tripling its mental health infrastructure since 2001, and a recent Rand study found that DOD outperforms civilian health systems in outpatient follow-up after psychiatric inpatient care for PTSD or depression, Colston told the panel.

"One of our largest tasks is better understanding why PTSD and TBI often present with depression, chronic pain, substance use disorders and suicide risk," he said, noting that longitudinal research efforts such as a 15-year study on TBI aid understanding and provide a framework for creating effective rehabilitation and support programs.

"We've evaluated over 150 mental health, TBI, substance use and suicide-prevention programs over the past five years, [and] this program evaluation has been invaluable," Colston said.

"Publication of this five-year study will be completed later this fiscal year and will help us … [ensure] our funding is tied to programs that work, such as the U.S. Army's embedded behavioral health program and its associated health data portal," he added.

In 2015, there were more 52,000 overdose deaths in America. Opiate overdose deaths went up to 10.4 per 100,000 in 2015. The DOD rate was 2.7 for 100,000, about one-fourth of that. This was accomplished because leaders were focused on service members' well-being and a focused outcome-based effort on prevention -- primary prevention, selective prevention and indicative prevention, drug testing, provider training, pharmacy protections and medication therapies, Colston told the panel.

"We hope to generalize some of the successes we've seen in PTSD and TBI incidents and opioid overdose deaths in other areas such as suicide prevention and alcohol use disorders," he said.

ESSENTIAL TO READINESS

In his remarks to the panel, Ivany said health care is essential to readiness, which is the Army's first priority. No area has faced as many challenges, made as many changes and achieved as many advances as Army behavioral health care, he told the House members.

"Early in the wars in Iraq and Afghanistan, the Army realized that the size and the organization of our behavioral health force was insufficient to meet the needs of our beneficiaries," Ivany said. Officials greatly increased resources and expanded the number of clinical programs, he added.

Senior Army medical leaders also made a pivotal decision to centralize the oversight and direction of all clinical programs and built a small team of professionals in the surgeon general's office to do so, he said. The team analyzed the effectiveness of clinical programs, identified best practices and replicated them across the force.

From this process came embedded behavioral health, which has reduced barriers to care for soldiers in combat units, and improved access and readiness.

"Today, over 450 providers in 62 embedded behavioral health teams support every operational unit in the Army," Ivany said, noting that soldiers receive care earlier and need less hospitalization to receive treatment.

Other innovations such as school behavioral health were drawn from the civilian sector. The Army embraced this approach and placed providers in schools on Army posts all over the world.

In TBI care, in partnership with DOD and other services, the Army has implemented a clear set of clinical standards and delivers them in interdisciplinary clinics across the force, Ivany said.

EXTENSIVE SCREENING

In his remarks, Pflanz said all Air Force mental health providers receive training in one or more of the several evidence-based therapies for PTSD, and all airmen can be confident that they will receive state-of-the-art treatment when they enter an Air Force mental health clinic.

"Even so," he said, "we're excited about the successful translation of research into clinical practice, including requiring evidence-based therapies for PTSD, event-driven protocols for recognizing TBI, and the use of progressive return activity in the management of concussion."

Other developments that help identify and manage these conditions include integrating behavioral health care into primary care clinics, embedding mental health professionals into operational units within highly stressed career fields, and comprehensive screening for PTSD and TBI following deployments and throughout an airmen's career, he said.

On the horizon, Pflanz added, the Invisible Wounds Clinic being established at Eglin Air Force Base, Florida, in 2018 will powerfully enhance PTSD and TBI treatments and will function as a referral center and a projection of treatment and expertise Air Force-wide.

"A multidisciplinary task force is identifying and resolving gaps in the continuum of care and the integrated delivery evaluation system for airmen suffering from invisible wounds," he said, noting that work is underway on 27 solutions ranging from education and training to culture and policy that will translate directly to improved services for the airmen.

INTERDISCIPLINARY TREATMENT

In his remarks, the director of the Navy's Intrepid Spirit Concussion Recovery Center said that about 80 percent of all TBIs are classified as mild. Those who have suffered mild TBIs may experience only subtle changes in mood, memory, sleep and balance. They have no visible signs of injury, Johnson said, but often struggle to function at work, at home and in the community.

"The reality is there is currently no diagnostic tool that is sensitive and specific for mild TBI," he said. "However, we have worked to overcome this [by] developing a holistic, integrated, interdisciplinary treatment model that employs a standard evaluation that includes physical, psychological and spiritual dimensions."

The center uses this information to diagnose and treat each patient with traditional therapies and complementary and integrative medicine, he added.

"We use a minimal amount of medication, almost no narcotics, and over 90 percent return to full duty upon completing the program," Johnson noted.

The Military Health System, in partnership with civilian academic institutions, has a robust research portfolio to address gaps in knowledge and improve care for service members with TBI, he said, including a progressive return-to-activity protocol that gives providers guidelines on how to increase activity in a way that maximizes recovery.

DOD is undertaking an ongoing longitudinal study of TBI in members of the armed forces to gain a better understanding of the condition and ensure patients receive the treatment they need, Johnson said.

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